{"paper_id":"c8fe3cb3-89ff-4b4e-b850-8e970f0ec294","body_text":"Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0)\n107\nLETTER TO THE EDITOR DOI: https://doi.org/10.5114/kitp.2020.97274 \nThoracic endometriosis syndrome (TES) is the presence \nof endometriotic foci within the respiratory system and in-\nvolves a range of symptoms that coincide with the menses. \nThese symptoms are defined as the presence of pneumo-\nthorax, hemothorax, hemoptysis, lung nodules, isolated \nchest pain, and pneumomediastinum. Catamenial pneu-\nmothorax (CP) is described as recurrent abnormal air col-\nlection between the lung and chest wall that occurs within \nthe first 72 hours of the menses and is the most common \npresentation of TES [1].\nAlthough it is considered quite a rare condition, 490 pa-\ntients have been reported so far. According to the current \nevidence, its prevalence is as high as 30% in women with \nspontaneous pneumothorax [2, 3]. Due to the lack of data \nin the literature, there is no definite information about the \nmanagement of recurrent cases.\nIn this report, we present a case with recurrent CP resis-\ntant to a variety of medical treatments managed via a mini-\nmally invasive approach by a multidisciplinary team.\nA 36-year-old, primiparous woman presented with \npersistent right shoulder pain and cyclic hemoptysis. She \nhad a history of seven CP episodes requiring pleurodesis \nin three of them. Her symptoms persisted, despite having \n6 months of cyclic OC treatment, dienogest for 6 months, \nand two courses of depot GnRHa. Her pelvic examination \nwas unremarkable, and a 3 cm endometrioma was ob-\nserved on her transvaginal ultrasound (TVUSG) examina-\ntion. A right pleural thickening was observed in computed \ntomography (CT) (Figure 1). After consulting anesthesiol-\nogy and thoracic surgery departments, an operative lapa-\nroscopy for peritoneal/diaphragmatic endometriosis and \nvideo-assisted thoracoscopy (VATS) was planned to treat \nrecurrent CP episodes.\nA double-lumen tube was used by an anesthesiologist \nto create a controlled collapse of the right lung for explor -\ning the chest cavity. After achieving adequate pneumo-\nperitoneum, a 10-mm intra-umbilical optical trocar was \ninserted. Two lateral and one suprapubic 5-mm accessory \ntrocars were then placed. An ultrasonic scalpel was used in \naddition to standard laparoscopic equipment.\nOn surgical exploration, about 2–3 cm endometriotic \nnodules were observed on paravesical leaves of the broad \nligament. Ureterolysis was performed before the excision of \nendometriotic nodules located on both of the sacrouterine \nligaments. A 3 cm endometrioma was observed on the right \novary, and right salpingo-oophorectomy was performed.\nMultiple superficial endometriotic lesions were ob-\nserved on the diaphragmatic peritoneal surface. Consider -\ning the patient’s complaints, we resected a wide peritoneal \nsurface of the diaphragm after blunt dissection by a mono-\npolar hook.\nThe VATS procedure was performed to identify any lung \ninvolvement and pleural involvement by a thoracic surgeon. \nOn exploration, a 6 × 5 cm pleural nodule surrounded with \nmultiple small endometriotic lesions was observed. The \nborders of the nodule were marked with a monopolar hook, \nand it was removed with a curved surgical clamp (Figure 2). \nAddress for corresepondence : Derya Ece Iliman MD, Obstetrics and Gynecology Department, Bakirkoy Dr. Sadi Konuk Research and Training \nHospital, Istanbul, Turkey, phone: +90 5066698815, e-mail: deryaeceiliman@gmail.com \nReceived: 20.05.2020, accepted: 10.06.2020.\nCatamenial pneumothorax: multidisciplinary minimally \ninvasive management of a recurrent case\nCihan Kaya1, Derya Ece Iliman1, Gun Murat Eyuboglu2, Ece Bahceci1\n1Obstetrics and Gynecology Department, Bakirkoy Dr. Sadi Konuk Research and Training Hospital, Istanbul, Turkey\n2Thoracic Surgery Department, Bakirkoy Dr.Sadi Konuk Research and Training Hospital, Istanbul, Turkey\nKardiochirur Torakochir Pol 2020; 17 (2): 107-109\nFigure 1. Computed tomography image. The black arrow shows \npleural thickening on the right side\n\nKardiochirurgia i Torakochirurgia Polska 2020; 17 (2)108\nCatamenial pneumothorax: multidisciplinary minimally invasive management of a recurrent case\nA wedge resection was performed with a stapler due to \na 0.5 cm suspicious endometriotic lesion placed on the \nlower right lung segment. After achieving hemostasis, col-\nlagen barriers were placed to have better tissue healing.  \nA 32 f thoracostomy tube was placed for drainage. The \npostoperative course was uneventful. A 6-month depot \nGnRH analogue treatment was planned to reduce postop-\nerative recurrence.\nAlthough various theories have been proposed to ex-\nplain the pathogenesis of TE [4], up to now, none can  \nexplain all features of the disease. These theories include \ncoelomic metaplasia, retrograde menstruation, migration \nof endometrial tissue, stem cell theory, microembolization \nthrough the pelvic veins, and abnormal lymphatic drainage. \nIt is commonly believed that the underlying cause is mul-\ntifactorial.\nCP is known as a typical symptom of TES, but it can oc-\ncur with no visible signs of thoracic endometriosis, and CP \nis the primary symptom of these patients [1–5].\n Current lit-\nerature mostly consists of case reports and small retrospec-\ntive studies. Ninety-five percent of cases occur at the right \nhemithorax, but left-sided and bilateral involvement also \nhas been described. The recurrence rate of CP was found \nto be 30–39% in various studies [5]. TES was found to be \nassociated with pelvic endometriosis (PE), and hemothorax \nwas the most frequent symptom of these patients [1–5].\n \n20–70% of CP patients have been reported to experience \npelvic endometriosis [3–5].\n As seen in our case, difficulties \nin the diagnosis, absence of a multidisciplinary team, and \ndelay in treatment could reduce the patients’ quality of life.\nCurrently, no guidelines have been released regarding \nthe appropriate diagnosis and treatment of TE. Acute CP \ntreatment is essentially surgical. The VATS procedure is \nmostly recommended to visualize any endometriotic le-\nsions on the pleura and any defects on the diaphragm [3]. \nThe current evidence suggests that resection or electro-\ncoagulation of endometriotic lesions may help to prevent \nfurther spreading and disease control. Other recommend-\ned surgical techniques include wedge resection, removal \nof blebs, diaphragmatic resection, and repair via patch, \nmesh, or simple suturing. One prospective study, including  \n32 patients, suggested that diaphragmatic defects can play \na crucial role in recurrent CP cases, and these defects al-\nmost always occur on the right side of the diaphragm [6].\nThe recurrence rates of CP after surgical treatment are \nrelatively high. In addition to surgery, suppressive medical \ntreatment can also be used in the postoperative period. For \nthat purpose, various hormonal therapies such as cyclic \nestrogen-progesterone combinations, GnRH agonists, da-\nnazol, and progesterone-only drugs were used. The most \neffective agent was reported to be a GnRH agonist, but due \nto the menopausal side effects of this treatment, it was \nonly recommended for short-term use in the pre- or post-\noperative period [3].\n Combined oral contraceptive (COC) \ntreatments are mostly found ineffective, as in our patient. \nYet, there is no reliable evidence on the optimal suppressor \nagent, dose regimen, or the success rates [3].\nRecurrence may also occur after surgical treatment. \nTalc pleurodesis was found highly effective, yet using this \ntreatment with non-malignant patients is still controver -\nsial [7].\n In a recent study, it was reported that a high rate \nof recurrence was observed after treatment with abrasion \npleurodesis alone. In our patient, despite having three \ncourses of pleurodesis treatment, recurrence was observed. \nWe may suggest that to reduce recurrence rates, removal \nof all visible endometriotic tissue is more feasible than \npleurodesis alone. Bagan et al. indicated that diaphragmat-\nic repair could lower the rate of recurrence and improves \noutcomes. They also recommended that covering the sur -\nface of the diaphragm with a polyglactin mesh was recom-\nFigure 2. A – Laparoscopic image. Black arrows show multiple superficial endometriotic lesions on the diaphragmatic peritoneal surface. \nB – VATS view. A 6 × 5 cm pleural nodule\nA B\n\nKardiochirurgia i Torakochirurgia Polska 2020; 17 (2) 109\nLETTER TO THE EDITOR\nmended, even if there are no visible diaphragmatic lesions \nor defects to reduce recurrence rates [4].\nTo sum up, CP is a diagnosis that can be easily over -\nlooked. Patients presenting with pneumothorax at repro-\nductive age should always be considered with this in mind. \nTreatment options can differ according to patient history, \ndesire to conceive, and persistence of episodes or symp-\ntoms. The medical and surgical combination treatments \nshould be considered in the foreground when appropri-\nate. The management of a multidisciplinary team may give \nthese patients a chance of a minimally invasive approach.\nDisclosure\nAuthors report no conflict of interest. \nReferences\n1. Joseph J, Sahn SA. Thoracic endometriosis syndrome: new observations from \nan analysis of 110 cases. Am J Med 1996; 100: 164-170. \n2. Haga T, Kataoka H, Ebana H, et al. Thoracic endometriosis-related pneu-\nmothorax distinguished from primary spontaneous pneumothorax in fe-\nmales. Lung 2014; 192: 583-587.\n3. Gil Y, Tulandi T. Diagnosis and treatment of catamenial pneumothorax: a sys-\ntematic review. J Minim Invasive Gynecol 2020; 27: 48-53. \n4. Bagan P, Le Pimpec Barthes F, Assouad J, et al. Catamenial pneumothorax: \nretrospective study of surgical treatment. Ann Thorac Surg 2003; 75: 378-381.\n5. Haga T, Kurihara M, Kataoka H, Ebana H. Clinical-pathological findings of \ncatamenial pneumothorax: comparison between recurrent cases and non-\nrecurrent cases. Ann Thorac Cardiovasc Surg 2014; 20: 202-206.\n6. Alifano M, Roth T, Broet SC, et al. Catamenial Pneumothorax. Chest 2003; \n124: 1004-1008.\n7. Alifano M, Trisolini R, Cancellieri A, et al. Thoracic endometriosis: current \nknowledge. Ann Thorac Surg 2006; 81: 761-769.","source_license":"CC0","license_restricted":false}